This application addresses broad Challenge Area (09) Health Disparities and specific Challenge Topic, 09-MD-101: Creating Transformational Approaches to Address Rural Health Disparities. A quasi-experimental clinical trial will test the effectiveness of the Critical Care Excellence in Sepsis and Trauma Program (CREST). The objective is to improve patient outcomes for sepsis and trauma by educating providers and providing access to specialist consultation via telemedicine technology to participating rural hospitals in the South Carolina (SC) Lowcountry and PeeDee regions. The Interstate-95 corridor transecting six SC counties is a predominantly rural area with a diverse patient population with limited health care resources. The healthcare and other disparities experienced by the 290,000 citizens of these counties are stark with 22% of the total population living below the federal poverty level, 4 of 6 being fully medically underserved, and 2 of 6 being partially medically underserved. Critical care and trauma care services and providers are in short supply. Without creative, alternative solutions to onsite intensivists and trauma specialists, rural hospitals will be unable to provide optimal care and patients with common critical conditions such as sepsis and trauma, will continue to pay a rural penalty of poorer outcomes. Substantial evidence supports reduced morbidity and mortality with intensivist- directed care for critically ill patients. Unfortunately, only 4% of US hospitals are estimated to meet this gold standard and over half have no intensivist coverage at all with rural hospitals being disproportionately affected. A major challenge is a national shortage of intensivists, trauma specialists, and other critical care staff, a problem likely to worsen as the population ages and demand for critical care increases. Furthermore, smaller hospitals often lack the economy of scale that makes a comprehensive critical care and trauma program feasible. Sepsis and trauma diagnoses represent over 1,700 visits annually to CREST hospitals'emergency departments and are leading causes for admission to an ICU. Nationally, sepsis is the 10th leading cause of death overall with increasing incidence as the population ages. Survival is directly related to appropriate initial evaluation and management in the first six critical hours. Trauma is the leading cause of death among Americans up to age 45 and the fourth leading cause for all ages. Trauma outcomes are directly related to management in the initial "golden" hour. Thus, both conditions represent high acuity, high stakes crises that provoke anxiety among non-specialist providers. Currently, rural Lowcountry patients suffering from these conditions do not have access to specialist directed care and are unlikely to acquire on-site access in the future. Via a public/private partnership using technological advances, CREST will test an economically efficient, creative, alternative solution to this dilemma. The care of patients with sepsis and trauma requires the delivery of appropriate, definitive care in the early stages of the illness. Hospitals with limited resources, including those in rural and underserved areas of the Low Country and Pee Dee regions of South Carolina, may be unable to consistently provide optimal care to these patients. In addition, the shortage of specialists nationally makes it more difficult for these hospitals to recruit and retain the specialists they need. Patients in these areas continue to pay the rural penalty of poorer outcomes. This proposal will provide specialist level care through telemedicine consults to rural emergency departments in the Low Country and Pee Dee regions of SC to improve outcomes for these patients.